Integrated Care

With integrated care, we are collaborating with healthcare providers and system administrators from partner organizations to improve patient transitions from UHN into the community. Our goal is to improve patient satisfaction and their overall health outcomes by following the patient post-discharge, providing the care that can be delivered directly in the home setting. This will ultimately prevent patients from unnecessary returns to the hospital, particularly for long waits in the Emergency Department. We are looking to our partner organizations and international models to develop a more seamless experience for patients, starting with streamlining care for UHN patients who are receiving thoracic surgeries.

Improving the patient experience through coordinated and integrated forms of care provision.

Project SPARK

SPARK is a UHN-led partnership working with eHealth Ontario and MaRS Discovery District that brings together thought leaders in digital health to stimulate consumer digital health innovation for Ontario. Ultimately, SPARK will help innovators get their products to patients, putting information in the hands of Ontarians faster.

Making it easier for digital health innovators to safely and securely flow provincial health information into the hands of patients and their health service providers.

Project OPEN

Project OPEN is a proof-of-concept that will demonstrate how digital enablers can be used to optimize population health and deliver better outcomes while lowering costs for Ontarians. While still in the proposal stage, early efforts are already being used to shape the provincial population health management framework to support the Patient’s First agenda. The initiative has also brought together a significant coalition of partners to look at new models of care in the community, including: The Association of Community Health Centres, Diabetes Action Canada, Ontario Telemedicine Network, THETA Collaborative, Toronto Central LHIN and Women’s College Hospital Institute for Health Systems Solutions in Virtual Care (WIHV).

Working with health care partners to explore new models of community care.

Centre of Excellence for Digital Health Delivery

We believe we are better together than the sum of our parts and we understand that no one organization can solve the challenges of advancing digital health in Ontario on its own. In order to be successful with regional health care delivery, we are working to cultivate collective impact by:

Applying a Health System Lens

Bringing sectors together to design and implement an integrated system of care through digital health.

Access to Specialist and Specialty Services: Improving specialist data quality on Specialist and Community Services Directory.

Bringing sectors together to design and implement an integrated system of care through digital health.

Resource Matching & Referral

The development of the Resource Matching & Referral (RM&R) program required an understanding of the healthcare landscape, the providers and vendors in the space, and possible technical solutions to create a roadmap for getting patients the correct level of care they need when they move within the healthcare system. This regional program currently supports 28,000 active users completing over 100,000 referrals per year, and enables seamless transition of patients between acute care, rehabilitation, complex continuing care, long term care, home case, palliative care, and community support services.

“Referral applications are more comprehensive through Toronto Central LHIN [RM&R], giving the care team a better understanding of the client’s current status. Admission decisions can be made easier without needing to follow up for more information” – Rehab/CCC facility

Enabling the timely transition of patients across the region to the right care, supporting 100,000+ referrals per year.

ConnectingOntario

ConnectingOntario delivered the first and largest electronic health record in Ontario, designed by clinicians for clinicians. Over the course of the program, we worked directly with 200 clinicians to utilize local expertise to guide the program both locally and regionally, and ensure clinicians were involved in end-to-end adoption efforts. Through this approach, clinicians have access to the priority clinical data they identified that enable the delivery of improved patient care across central Ontario. ConnectingOntario evolved from ConnectingGTA, and efforts are underway to make it more accessible to primary care providers.

“I use ConnectingGTA routinely! The tool has allowed for access to information that was not previously available such as CCAC services. This cuts down on unnecessary referrals, assisting patients in navigating their own care,” Registered Nurse, Palliative Outpatient Clinic, UHN

Delivering Ontario’s first and largest electronic health record.

Critical Care Information System (CCIS)

We were responsible for the solution development and implementation of a Critical Care Information System (CCIS), which provides real-time data on patients in clinical care units, enabling the monitoring and managing of critical care resources for 200 critical care units across Ontario. We worked with hospitals, vendors, 14 LHINs and others to successfully complete the project.

Enabling the monitoring and managing of Ontario’s critical care resources.

Patient Results Online

Developed to ease patient transition from one care setting to another, Patient Results Online (PRO) allows clinicians to access patient health information stored in different data repositories in real time. This has reduced the need for extensive patient history interviews and reduction of lab test duplications since the clinicians can see the patient’s care journey. Taking a service design approach, consultation with various stakeholders were completed in order to understand the functionalities required and to create a simple user interface.